NUR 216 Exam 4
1. What is the correct Correct Order: B. Inspect, auscultate, percuss, palpate
order for performing
an abdominal assess- Rationale: Inspection and auscultation are performed first to prevent al-
ment? tering bowel sounds, followed by percussion and palpation to assess for
A. Percuss, palpate, tenderness or masses.
auscultate, inspect
B. Inspect, auscultate,
percuss, palpate
C. Palpate, inspect,
auscultate, percuss
D. Auscultate, palpate,
inspect, percuss
2. During an abdomi- Answer: C. Diarrhea
nal assessment, the
nurse hears hyper- Rationale: Hyperactive bowel sounds indicate increased gastrointestinal
active bowel sounds. motility, commonly associated with diarrhea.
Which condition is
most likely?
A. Paralytic ileus
B. Peritonitis
C. Diarrhea
D. Bowel obstruction
3. A nurse is assessing a Answer: B. Dullness over the flanks
client with suspected
ascites. What finding Rationale: Dullness over the flanks is characteristic of fluid accumulation
is expected?A. Tympa- in ascites, whereas tympany would suggest air.
ny over the abdomen
B. Dullness over the
flanks
C. Pulsations in the
, NUR 216 Exam 4
umbilical region
D. Generalized rigidity
4. What is the priority Answer: D. Peritonitis
concern when rigidi-
ty is noted during ab- Rationale: Rigidity is a sign of peritoneal irritation, often caused by peri-
dominal assessment? tonitis, which requires immediate medical attention.
A. Appendicitis
B. Dehydration
C. Internal bleeding
D. Peritonitis
5. When auscultating the Answer: B. Bruit over the abdominal aorta
abdomen, which of
the following findings Rationale: A bruit may indicate an abdominal aortic aneurysm, which is a
should be reported medical emergency. Other findings like absent bowel sounds should also
immediately to the be reported but are less immediately critical.
provider?
A. Borborygmi
B. Bruit over the ab-
dominal aorta
C. Absent bowel
sounds after 2 min-
utes
D. Hypoactive bowel
sounds
6. A client presents with Answer: B. Gastric bleeding
black, tarry stools.
What condition does Rationale: Black, tarry stools (melena) are indicative of upper gastroin-
this most likely indi- testinal bleeding, commonly caused by gastric or duodenal ulcers.
cate?
, NUR 216 Exam 4
A. Hemorrhoids
B. Gastric bleeding
C. Constipation
D. Intestinal perfora-
tion
7. Select-all-that-apply: Priority Findings: A. Distension; B. Bruit over the aorta; C. Epichmosis
Which findings should
a nurse prioritize Rationale: Abdominal distension, a bruit, and bruising (epichmosis) are
when assessing the abnormal and may indicate life-threatening conditions like internal bleed-
abdomen? ing or organ dysfunction.
A. Distension
B. Bruit over the aorta
C. Epichmosis
D. Normal bowel
sounds
8. The spleen is located Answer: D. LUQ
in which quadrant of
the abdomen? Rationale: The spleen is located in the left upper quadrant (LUQ) of the
A. RLQ abdomen.
B. LLQ
C. RUQ
D. LUQ
9. A nurse is palpating Answer: C. Urinary retention
a client's bladder dur-
ing assessment. What Rationale: A palpable bladder suggests urinary retention, which may re-
should this indicate? quire intervention such as catheterization.
A. Normal findings
B. Bladder infection
, NUR 216 Exam 4
C. Urinary retention
D. Overactive bladder
10. What does pyrosis re- Answer: B. A burning sensation in the chest and throat
fer to?
A. Gas buildup in the Rationale: Pyrosis refers to heartburn, a common symptom of gastroe-
intestines sophageal reflux disease (GERD).
B. A burning sensa-
tion in the chest and
throat
C. Vomiting blood
D. Decreased appetite
11. A nurse is teaching Answer: C. Inspect the breasts in a mirror for dimpling or discharge
a client how to per-
form a breast self-ex- Rationale: Visual inspection is critical for identifying changes like dimpling
amination. Which of or discharge, which could indicate breast cancer.
the following instruc-
tions should the nurse
include?
A. Use the palm of the
hand to palpate for
lumps.
B. Perform the
exam once every six
months.
C. Inspect the breasts
in a mirror for dim-
pling or discharge.
D. Use cold water to in-
crease breast sensitiv-
ity during the exam.
1. What is the correct Correct Order: B. Inspect, auscultate, percuss, palpate
order for performing
an abdominal assess- Rationale: Inspection and auscultation are performed first to prevent al-
ment? tering bowel sounds, followed by percussion and palpation to assess for
A. Percuss, palpate, tenderness or masses.
auscultate, inspect
B. Inspect, auscultate,
percuss, palpate
C. Palpate, inspect,
auscultate, percuss
D. Auscultate, palpate,
inspect, percuss
2. During an abdomi- Answer: C. Diarrhea
nal assessment, the
nurse hears hyper- Rationale: Hyperactive bowel sounds indicate increased gastrointestinal
active bowel sounds. motility, commonly associated with diarrhea.
Which condition is
most likely?
A. Paralytic ileus
B. Peritonitis
C. Diarrhea
D. Bowel obstruction
3. A nurse is assessing a Answer: B. Dullness over the flanks
client with suspected
ascites. What finding Rationale: Dullness over the flanks is characteristic of fluid accumulation
is expected?A. Tympa- in ascites, whereas tympany would suggest air.
ny over the abdomen
B. Dullness over the
flanks
C. Pulsations in the
, NUR 216 Exam 4
umbilical region
D. Generalized rigidity
4. What is the priority Answer: D. Peritonitis
concern when rigidi-
ty is noted during ab- Rationale: Rigidity is a sign of peritoneal irritation, often caused by peri-
dominal assessment? tonitis, which requires immediate medical attention.
A. Appendicitis
B. Dehydration
C. Internal bleeding
D. Peritonitis
5. When auscultating the Answer: B. Bruit over the abdominal aorta
abdomen, which of
the following findings Rationale: A bruit may indicate an abdominal aortic aneurysm, which is a
should be reported medical emergency. Other findings like absent bowel sounds should also
immediately to the be reported but are less immediately critical.
provider?
A. Borborygmi
B. Bruit over the ab-
dominal aorta
C. Absent bowel
sounds after 2 min-
utes
D. Hypoactive bowel
sounds
6. A client presents with Answer: B. Gastric bleeding
black, tarry stools.
What condition does Rationale: Black, tarry stools (melena) are indicative of upper gastroin-
this most likely indi- testinal bleeding, commonly caused by gastric or duodenal ulcers.
cate?
, NUR 216 Exam 4
A. Hemorrhoids
B. Gastric bleeding
C. Constipation
D. Intestinal perfora-
tion
7. Select-all-that-apply: Priority Findings: A. Distension; B. Bruit over the aorta; C. Epichmosis
Which findings should
a nurse prioritize Rationale: Abdominal distension, a bruit, and bruising (epichmosis) are
when assessing the abnormal and may indicate life-threatening conditions like internal bleed-
abdomen? ing or organ dysfunction.
A. Distension
B. Bruit over the aorta
C. Epichmosis
D. Normal bowel
sounds
8. The spleen is located Answer: D. LUQ
in which quadrant of
the abdomen? Rationale: The spleen is located in the left upper quadrant (LUQ) of the
A. RLQ abdomen.
B. LLQ
C. RUQ
D. LUQ
9. A nurse is palpating Answer: C. Urinary retention
a client's bladder dur-
ing assessment. What Rationale: A palpable bladder suggests urinary retention, which may re-
should this indicate? quire intervention such as catheterization.
A. Normal findings
B. Bladder infection
, NUR 216 Exam 4
C. Urinary retention
D. Overactive bladder
10. What does pyrosis re- Answer: B. A burning sensation in the chest and throat
fer to?
A. Gas buildup in the Rationale: Pyrosis refers to heartburn, a common symptom of gastroe-
intestines sophageal reflux disease (GERD).
B. A burning sensa-
tion in the chest and
throat
C. Vomiting blood
D. Decreased appetite
11. A nurse is teaching Answer: C. Inspect the breasts in a mirror for dimpling or discharge
a client how to per-
form a breast self-ex- Rationale: Visual inspection is critical for identifying changes like dimpling
amination. Which of or discharge, which could indicate breast cancer.
the following instruc-
tions should the nurse
include?
A. Use the palm of the
hand to palpate for
lumps.
B. Perform the
exam once every six
months.
C. Inspect the breasts
in a mirror for dim-
pling or discharge.
D. Use cold water to in-
crease breast sensitiv-
ity during the exam.
